Basic Information
| Provider Information | |||||||||
| NPI: | 1326566803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | KACIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 489 WALNUT DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322597010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047715223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
| FaxNumber: | 4077925693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 30999 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.